Clinical presentation and diagnosis of colonic perforative peritonitis

INTRODUCTION: Colonic perforative peritonitis (CPP) is a life-threatening surgical emergency where timely diagnosis is of ultimate impact on outcome. MATERIALS AND METHODS: For a five-year period (2014 – 2018), 62 patients with CPP were treated in First Clinic of Surgery in St. George University Hospital - Plovdiv. Males were 48 (77.42%) and females 14 (22.58%), with a ratio of 3.4:1. Patients’ age ranged from 14 to 92 years, with an average age of 71 years ± 2.4. Colonic perforative peritonitis was more common in patients over 80 years of age (n=21; 33.87%). The main causes of CPP were: perforated colon diverticulitis (n=19), perforated colon cancer (n=18), perforation in incarceration (n=9), sigmoid volvulus (n=6), mesenteric ischemia (n=5) and miscellaneous (n=5). There were 12 patients with local peritonitis (19.36%), with diffuse peritonitis - 21 patients (33.87%), and with total peritonitis - 29 patients (46.77%). The following surgical procedures were performed: Hartmann’s procedure – 21, right hemicolectomy - 13, left hemicolectomy - 9, right hemicolectomy with ileostomy - 8,  diverticulectomy - 7,  colon excision and suture - 4. RESULTS: Twenty-four patients (38.71%) were вith subacute perforation type (38.71%), while 38 (61.29%) were with acute type.  Atypical clinical presentation with vague symptoms was found in 7 patients (11.29%). Early clinical symptoms in subacute and atypical forms of CPP were nonspecific.  According to the elapsed time from the beginning of the perforation to the operation, the patients were divided as follows: up to the 6th hour - 24 (38.71%), from the 6th to the 12th hour - 19 (30.65%), from the 12th to the 24th hour - 12 (19.35%), and over 24 hours - 7 (11.29%). Of the total 62 operated patients with CPP, 49 patients (79.03%) survived. Postoperative mortality was 20.97% (n=13) with an average age of 78.9 years. CONCLUSION: Early diagnosis of colonic perforation can be difficult, due to omissions and inaccuracies on admittion and follow-up. The correct and timely diagnosis of CPP is crucial for prompt surgery, lower morbidity and mortality and better outcome.